Tumor Staging

The over-riding controversy regarding specimen morcellation is the reduced ability to determine tumor stage. While the importance of histologic diagnosis is well-accepted, the clinical utility of precise pathologic staging is less clear.

Proponents of intact specimen extraction cite the inaccuracy of staging by preopera-tive imaging studies (3). Computed tomography overestimated and understaged tumors in 10% and 9% of patients, respectively. It is assumed that morcellation destroys the ability to identify pathologic features such as invasion into the renal vein, perinephric fat, and adrenal gland. However, Landman et al. suggested that morcellated fragments can yield evidence of perinephric fat involvement (100%) and rein vein thrombus (100%) (42). Pautler et al. also provided evidence that perinephric invasion can be identified after manual morcellation, although the true accuracy cannot be determined (43). We have made similar observations, with identification of higher pathologic stage despite morcellation.

The imprecision of clinical staging based on imaging compared to pathologic staging of an intact specimen will always remain. Furthermore, adverse pathologic features such as extension into fat or the renal vein are associated with worse onco-logic outcomes. This information is important for determining surveillance regimens as well as patient counseling. However, outside of clinical trials, adjuvant therapy is not currently indicated in these situations. Therefore, the actual clinical impact of not recognizing microscopic fat invasion is limited. Indeed, the excellent five-year outcomes of the laparoscopic approach, with morcellation, for smaller renal tumors confirm the efficacy of the operation and absence of clinical implication. If more advanced stage is suspected on imaging studies and consideration of adjuvant therapy is dependent on this information, intact specimen retrieval should be performed. Future molecular characterization and stratification of renal tumors, and less dependence on pathologic stage, may predict recurrence or need for secondary treatment and shift preference toward morcellation.

In addition to affecting accurate pathologic staging, morcellation also obscures the nature of surgical margin status. Similar to higher pathologic stage, the presence of a positive surgical margin does not necessarily change postoperative treatment but would potentially increase the frequency of subsequent imaging. Nevertheless, accurate evaluation of surgical margins plays several roles. Negative surgical margins confirm the oncologic adequacy of the laparoscopic approach to the kidney with tumor. The excellent cancer outcomes, without significant rates of local tumor recurrence, indirectly indicate that the laparoscopic technique has not been associated with increased rates of positive surgical margins. This may be important to document as the techniques are increasingly performed (i) by those less experienced with laparoscopy, and (ii) in patients with larger and more advanced cancers. A positive surgical margin portends a worse prognosis and allows appropriate counseling of the patient, while the confirmation of a negative surgical margin is reassuring to both the patient and physician.

Few studies have addressed the question of surgical margin status in morcellated laparoscopic specimens. In an in vitro model, various substances were tested for their ability to mark the margins of bovine kidneys prior to manual morcellation (45). Undiluted india ink was superior to methylene blue and indigo carmine with respect to covering the surface, retention after washing, and microscopically visible after routine processing and hematoxylin-eosin staining. India ink is clinically safe and has been extensively used in vivo in humans. Overall, accurate pathologic study of renal specimens will become more crucial as minimally invasive surgery grows, and novel and alternative methods of determining surgical margin as well as biological behavior are necessary.

SUMMARY

■ The ability to remove the entire kidney laparoscopically, and widespread dissemination of the technique, has created the dilemma of specimen retrieval.

Current data indicate that careful manual morcellation is safe and does not compromise oncologic outcomes, but only further observation will confirm this.

When performed properly, specimen morcellation after laparoscopic nephrectomy is acceptable, and is particularly appropriate in those undergoing cytoreductive nephrectomy prior to systemic immunotherapy.

The impacts of morcellation on pathological assessment are primarily theoretical and do not typically alter treatment schemes.

The primary benefit of specimen morcellation is cosmetic. After laparoscopic nephrectomy, the exact method of specimen handling is likely unimportant with respect to pain and convalescence. The decision of how to remove the kidney is ultimately based on patient and surgeon preference and made after thorough discussion of the relevant issues.

REFERENCES

Chan DY, Cadeddu JA, Jarrett TW, Marshall FF, Kavoussi LR. Laparoscopic radical nephrectomy: cancer control for renal cell carcinoma. J Urol 2001; 166:2095.

Portis AJ, Yan Y, Landman J, et al. Long-term followup after laparoscopic radical nephrectomy. J Urol 2002; 167:1257.

Gill IS, Meraney AM, Schweizer DK, et al. Laparoscopic radical nephrectomy in 100 patients: a single center experience from the United States. Cancer 2001; 92:1843.

Gill IS, Cherullo EE, Meraney AM, Borsuk F, Murphy DP, Falcone T. Vaginal extraction of the intact specimen following laparoscopic radical nephrectomy. J Urol 2002; 167:238.

Matin SF, Gill IS. Modified Pfannenstiel incision for intact specimen extraction after retroperitoneo-scopic renal surgery. Urology 2003; 61:830.

Savage SJ, Gill IS. Intact specimen extraction during renal laparoscopy: muscle-splitting versus muscle-cutting incision. J Endourol 2001; 15:165.

Barrett PH, Fentie DD, Taranger LA. Laparoscopic radical nephrectomy with morcellation for renal cell carcinoma: the Saskatoon experience. Urology 1998; 52:23.

Walther MM, Lyne JC, Libutti SK, Linehan WM. Laparoscopic cytoreductive nephrectomy as preparation for administration of systemic interleukin-2 in the treatment of metastatic renal cell carcinoma: a pilot study. Urology 1999; 53:496.

9. Pryor WR. The Treatment of Pelvic Inflammations Through the Vagina. Philadelphia: W.B. Saunders, 1899:209-215.

10. Lash AF. Amethod for reducing the size of the uterus in vaginal hysterectomy. Am J Obstet Gynecol 1941; 42:452.

11. Kovac SR. Intramyometrial coring as an adjunct to vaginal hysterectomy. Obstet Gynecol 1986; 67:131.

12. Melose MA, Melosi MA III. Laparoscopic hysterectomy with bilateral salpingo-oophorectomy using a single umbilical puncture. N J Med 1991; 88:721.

13. Steiner RA, Wight E, Tadir Y, Haller U. Electrical cutting device for laparoscopic removal of tissue from the abdominal cavity. Obstet Gynecol 1993; 81:471.

14. al-Ahmadi M, Brundage S, Brody F, Jacobs L, Sackier JM. Splenosis of the mesoappendix: case report and review of the literature. J R Coll Surg Edinb 1988; 43:200.

15. Sepilian V, Della Badia C. Iatrogenic endometriosis caused by uterine morcellation during a supracervical hysterectomy. Obstet Gynecol 2003; 102:1125.

16. Hutchins FL, Reinoehl EM. Retained myoma after laparoscopic supracervical hysterectomy with morcellation. J Am Assoc Gynecol Laparosc 1998; 5:293.

17. Schneider AL. Recurrence of unclassifiable uterine cancer after modified hysterectomy with morcellation. Am J Obstet Gynecol 1997; 177:478.

18. EndoCatch Gold product information. Available at: www.autosuture.com/products/endocatch-gold/ (accessed on June 1, 2004).

19. Urban DA, Kerbl K, McDougall EM, Stone AM, Fadden PT, Clayman RV. Organ entrapment and renal morcellation: permeability studies. J Urol 1993; 150:1792.

20. Sundaram CP, Ono Y, Landman J, Rehman J, Clayman RV. Hydrophilic guidewire technique to facilitate organ entrapment using a laparoscopic sack during laparoscopy. J Urol 2002; 167:1376.

21. Pautler SE, Harrington FS, McWilliams GW, Walther MM. A novel laparoscopic specimen entrapment device to facilitate morcellation of large renal tumors. Urology 2002; 59:591.

22. User HM, Nadler RB. Novel technique of renal entrapment for morcellation. J Urol 2003; 169:2287.

23. Landman J, Collyer WC, Olweny E, Andreoni C, McDougall E, Clayman RV. Laparoscopic renal ablation: an in vitro comparison of currently available electrical tissue morcellators. Urology 2000; 56:677.

24. Parekh AR, Moran ME, Newkirk RE, Desai PJ, Calvano CJ. Tissue removal utilizing Steiner Morcellator within a LapSac: effects of a fluid-filled environment. J Endourol 2000; 14:185.

25. Cai Y, Jacobson A, Marcovich R, et al. Electrical prostate morcellator: an alternative to manual morcellation for laparoscopic nephrectomy specimens? An in vitro study. Urology 2003; 61:1113.

26. Varkarakis JM, McAllister M, Ong AM, et al. Evaluation of water jet morcellation as an alternative to hand morcellation of renal tissue ablation during laparoscopic nephrectomy: an in vitro study. Urology 2004; 63:796.

27. Landman J, Venkatesh R, Kibel A, Vanlangendonck R. Modified renal morcellation for renal cell carcinoma: laboratory experience and early clinical application. Urology 2003; 62:632.

28. Elashry OM, Giusti G, Nadler RB, McDougall EM, Clayman RV. Incisional hernia after laparoscopic nephrectomy with intact specimen removal: caveat emptor. J Urol 1997; 158:363.

29. Jacobs SC, Cho E, Dunkin BJ, et al. Laparoscopic live donor nephrectomy: the University of Maryland 3-year experience. J Urol 2000; 164:1494.

30. Ratner LE, Montgomery RA, Kavoussi LR. Laparoscopic live donor nephrectomy: the four year Johns Hopkins University experience. Nephrol Dial Transplant 1999; 14:2090.

31. Shekarriz B, Gholami SS, Rudnick DM, Duh QY, Stoller ML. Radially expanding laparoscopic access for renal/adrenal surgery. Urology 2001; 58:683.

32. Ono Y, Kinukawa T, Hattori R, Gotoh M, Kamihira O, Ohshima S. The long-term outcome of laparoscopic radical nephrectomy for small renal cell carcinoma. J Urol 2001; 165:1867.

33. Fentie DD, Barrett PH, Taranger LA. Metastatic renal cell cancer after laparoscopic radical nephrectomy: long-term follow-up. J Endourol 2000; 14:407.

34. Castilho LN, Fugita OE, Mitre AI, Arap S. Port site tumor recurrences of renal cell carcinoma after videolaparoscopic radical nephrectomy. J Urol 2001; 165:519.

35. Landman J, Clayman RV. Re: Port site tumor recurrences of renal cell carcinoma after videolaparoscopic radical nephrectomy. J Urol 2001; 166:629.

36. Tsivian A, Sidi AA. Port site metastases in urological laparoscopic surgery. J Urol 2003; 169:1213.

37. Ono Y, Kinukawa T, Hattori R, et al. Laparoscopic radical nephrectomy for renal cell carcinoma: a five-year experience. Urology 1999; 53:280.

38. Dunn MD, Portis AJ, Shalhav AL, et al. Laparoscopic versus open radical nephrectomy: a 9-year experience. J Urol 2000; 164:1153.

39. Gettman MT, Napper C, Corwin TS, Cadeddu JA. Laparoscopic radical nephrectomy: prospective assessment of impact of intact versus fragmented specimen removal on postoperative quality of life. J Endourol 2002; 16:23.

40. Hernandez F, Rha KH, Pinto PA, et al. Laparoscopic nephrectomy: assessment of morcellation versus intact specimen extraction on postoperative status. J Urol 2003; 170:412.

41. Meng MV, Koppie TM, Stoller ML. Pathologic sampling of laparoscopically morcellated kidneys: a mathematical mode. J Endourol 2003; 17:229.

42. Landman J, Lento P, Hassen W, Unger P, Waterhouse R. Feasibility of pathological evaluation of morcellated kidney after radical nephrectomy. J Urol 2000; 164:2086.

43. Pautler SE, Hewitt SM, Linehan WM, Walther MM. Specimen morcellation after laparoscopic radical nephrectomy: confirmation of histologic diagnosis using needle biopsy. J Endourol 2002; 16:89.

44. Meng MV, Miller TR, Cha I, Stoller ML. Cytology of morcellated renal specimens: significance in diagnosis and dissemination. J Urol 2003; 169:45.

45. Meng MV, Koppie TM, Duh Q-Y, Stoller ML. Novel method of assessing surgical margin status in laparoscopic specimens. Urology 2001; 58:677.

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